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I did a search, and did not find this scenario, although it's probably out there.
Our primary care physician, who we have been using for decades, refused to make an appointment for my husband who is now on Medicare. The practice does take a certain Medicare Advantage program, but does not take traditional Medicare. We were quite aware of this, but my husband chose to see him on a cash basis.
He was refused! We were even told that Medicare could fine them if they saw him on a cash basis. Whaaa??? Anyone know if that is true or just a line being fed to patients?
I have to admit I am shocked and angry and considering moving to another PCP myself, even though I have 5 more years to Medicare.
Afaik, Medicare fines its docs if they don't collect Medicare copays - not for seeing Medicare patients who choose to pay cash and not bother with Medicare at all.
Who told your hubby this? Was it the doc or one of the office people? Either way, I don't think they know what they are talking about.
There are a couple of other posters here who are more in the weeds on Medicare rules who might have more insight.
Thanks, Ariadne22, I am inclined to think it's a line of BS. I do not understand a cash patient being turned away.
It was one of the front office people that told him this. He needed to make the appointment, and happened to be in the neighborhood, so this was a face-to-face conversation. Afterward, to check again, I called the appointment desk by phone, and got the same story.
Dumb question - but why would the doc's office even need to know about Medicare if you plan to use cash?
Exactly. Many people collecting Social Security have Medicare Part A for hospital because it's free, but don't enroll in Part B (doctors, labs, outpatient etc.) because Part B has a premium. It is quite possible for someone of Medicare age not to have Medicare coverage at all, as well - for a variety of reasons. Never paid into the system, immigrants, etc. For some of these people, it is possible to buy into Medicare, but it's fairly expensive - between Part A ($411) and Part B ($122) - $533/mo.
Further to this, I see a chiropractor who takes Medicare patients. In the beginning, my claims were submitted to Medicare. After a while, to avoid the constant exams and questionnaires and b/c Medicare doesn't pay for maintenance, he stopped submitting to Medicare. Now, when I see him, I am charged his Medicare reimbursement of $28.54 per adjustment, for which I pay cash. He still sees other Medicare patients and submits to Medicare, just not for me.
Last edited by Ariadne22; 08-23-2016 at 02:38 PM..
If the provider agrees to see the Medicare beneficiary, the Social Security Act (Section 1848(g)(4)(A)) requires that claims be submitted to Medicare for all beneficiaries for "covered services" rendered on or after September 1, 1990. This does not apply to the very small number of providers that have formally opted out of Medicare and does not apply to non-covered services.
Section 1848(g)(4)(B)(ii) is the penalty enforcement.
Quote:
(ii) If a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A)) fails to submit a claim required to be submitted under subparagraph (A) or imposes a charge in violation of such subparagraph, the Secretary shall apply the sanction with respect to such a violation in the same manner as a sanction may be imposed under section 1842(p)(3) for a violation of section 1842(p)(1).
The Medicare Benefit Policy Manual, Ch. 15, Section 40 provides an exception to this rule when the beneficiary refuses to allow the provider to submit the covered service to Medicare. However, this exception does not apply in your case since it is the provider who does not take Medicare.
If the provider agrees to see the Medicare beneficiary, the Social Security Act (Section 1848(g)(4)(A)) requires that claims be submitted to Medicare for all beneficiaries for "covered services" rendered on or after September 1, 1990.
This does not apply to the very small number of providers that have formally opted out of Medicare and does not apply to non-covered services.
Section 1848(g)(4)(B)(ii) is the penalty enforcement.
The Medicare Benefit Policy Manual, Ch. 15, Section 40 provides an exception to this rule when the beneficiary refuses to allow the provider to submit the covered service to Medicare.
However, this exception does not apply in your case since it is the provider who does not take Medicare.
So, the conclusion in OP's case is although this doc takes Medicare Advantage, he does not take Original Medicare and has, thus, "formally opted out of Medicare?"
How is it possible for a Medicare Advantage provider to "formally opt out of Medicare?" Doesn't he need to be a Medicare provider to be part of an Advantage plan network?
In either case, then doc can still see patient for cash either because:
patient "refuses to allow the provider to submit the covered service to Medicare" or,
if doc is not part of Medicare at all, he can do what he wants.
What am I missing, here?
Last edited by Ariadne22; 08-23-2016 at 04:43 PM..
So, the conclusion in OP's case is although this doc takes Medicare Advantage, he does not take Original Medicare and has, thus, "formally opted out of Medicare?"
In either case, then doc can still see patient for cash either because:
patient "refuses to allow the provider to submit the covered service to Medicare" or,
if doc is not part of Medicare at all, he can do what he wants.
What am I missing, here?
There are different levels of relationship between providers and Medicare. A provider can be:
1) Participating - Always submits claims to Medicare and always accepts assignment.
2) Non-Participating - Has the option of seeing Medicare beneficiaries or not. If they do agree to see the bene they must submit the claim to Medicare. Has the option of accepting assignment or not.
3) Formally Opted Out - This is a very, very, very, small number of providers who have submitted paperwork to CMS. If they choose to see a Medicare beneficiary, they are required to have the bene sign a form stating they have been informed the provider has opted out and are responsible for setting up payment terms, including cash payments.
4) No relationship - The provider has no relationship with Original Medicare. In general, they do not see Original Medicare beneficiaries. If they have not been sanctioned by their state licensing board, they can still join a Medicare Advantage network. I believe the OP's provider falls into this category, although it could also be non-participating. The provider cannot see the beneficiary for cash.
The provider has to be willing to accept the Original Medicare beneficiary (and submit claims) first before the bene can invoke the Benefit Policy exception. The OP stated the provider does not accept Original Medicare beneficiaries.
4) No relationship - The provider has no relationship with Original Medicare. In general, they do not see Original Medicare beneficiaries. If they have not been sanctioned by their state licensing board, they can still join a Medicare Advantage network. I believe the OP's provider falls into this category, although it could also be non-participating. The provider cannot see the beneficiary for cash.
So, in essence, this provider is forbidden to see anyone insured under Original Medicare who is willing to pay cash. Makes absolutely no sense. I would like to see this tested in the courts.
Dumb question - but why would the doc's office even need to know about Medicare if you plan to use cash?
While I was not present during the conversation, the front desk always asks for the patient's current insurance. I am certain my husband mentioned being on Medicare, not knowing it would cause an issue. He went on to clarify he would be a cash patient.
Thank you for the new information, SSGameCock. However, I agree with Ariadne22, it makes absolutely no sense at all. In our case, it is quite inconvenient and undesirable. The visit was a requirement from a specialist, who will be performing a minor surgery on my husband. The specialist's office requires a sign-off from a PCP to move forward. We have now been forced to make an appointment with a new doctor that accepts traditional Medicare for some basic tests (EKG, chest-xray, etc). For some reason I also fail to understand, the specialist office will not accept this from any other type of doctor, only a PCP. My husband also has an internist, but that wasn't good enough either.
Healthcare is insane nowadays.
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